| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of the inspection, the toilet in the upstairs bathroom had dried fecal matter all over the toilet, inside and outside. During the inspection, the home was extremely clutter and had trash on the floor throughout the home. | Clean and sanitary conditions shall be maintained in the home. | 1. A plan to fix the immediate problem
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring the cleanliness and sanitation of the homes in which they work in. QLS management will be responsible for weekly home inspections. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. |
02/02/2024
| Implemented |
| 6400.71 | At the time of the inspection, there was no emergency numbers on the phone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| 1. A plan to fix the immediate problem
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring that all phones have a label with the appropriate numbers listed on them at all times. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. |
02/02/2024
| Implemented |
| 6400.76(a) | At the time of the inspection, the couch was dirty, ripped, and sunken in. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management, Maintenance and Staff
b. WHAT: QLS staff will be responsible for that all furniture is nonhazardous, clean and sturdy in the homes they work in. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. QLS Staff immediately report any issues with furniture to the QLS management team. QLS Maintenance will address, repair or replace any items in question. |
02/02/2024
| Implemented |
| 6400.77(b) | At the time of the inspection there were no scissors or tweezers located in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring that all first aid kits are equipped and well maintained with the appropriate items. QLS management will be responsible for weekly home inspections, including a comprehensive inventory check of the first aid kits. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. |
02/02/2024
| Implemented |
| 6400.77(c) | At the time of the inspection, there was not a manual located in the first aid kit. | A first aid manual shall be kept with the first aid kit. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring that all first aid kits are equipped and well maintained with the appropriate items. QLS management will be responsible for weekly home inspections, including a comprehensive inventory check of the first aid kits. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. |
02/02/2024
| Implemented |
| 6400.101 | The doorway in the basement leading to the outside was not closed all the way at the time of the inspection. The door would not close completely nor would it open. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1. A plan to fix the immediate problem
a. WHO: QLS Management, Maintenance and Staff
b. WHAT: QLS staff will be responsible for ensuring that stairways, halls, doorways and exits from rooms and buildings are unobstructed. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly.
c. WHEN and HOW: On 1/3/2024 QLS maintenance arrived at the home to fix the door in question |
02/02/2024
| Implemented |
| 6400.144 | At the time of the inspection, none of the individual's medications were available at the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 1. A plan to fix the immediate problem.
a. WHO: QLS Management and Staff
b. WHAT: QLS Management will ensure that all PRN medications are always available in the home to the individuals. QLS staff will audit and report PRN medication needs.
c. WHEN and HOW: Effective 2/1/2024 all PRN medications will be audited by staff members in the homes weekly and reported back to the Medical Coordinator by Tuesdays at noon of any medications that are low, or close to expiration. |
02/02/2024
| Implemented |
| 6400.214(a) | At the time of the inspection, there was not a current copy of the ISP or assessment available in the home. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management
b. WHAT: QLS Management will ensure that the staff have access to the most recent assessment, physical, ISP, Behavior Support Plan and any other pertinent information specific to the individual being served
c. WHEN and HOW: QLS Program Specialist, Medical Coordinator and Behavior Specialist will ensure that all records are kept in digital and paper form in the homes for the staff by 2/1/2024. |
02/05/2024
| Implemented |
| 6400.32(q) | Individual #1 has been requesting a new couch for the last year and a half and no steps have been taken to purchase a new couch for the individual. | An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). | 1. A plan to fix the immediate problem.
a. WHO: QLS Training Coordinator, QLS Management
b. WHAT: QLS Training Coordinator will ensure staff are trained, QLS Program Specialists will ensure to monitor the treatment of individuals and their rights via in person monitoring.
c. WHEN and HOW: QLS Training Coordinator will ensure that all QLS employees are trained on the new policy (depicted below) by 2/1/2024. QLS Program Specialists will monitor the quality care of the individuals at least monthly. |
02/02/2024
| Implemented |
| 6400.163(d) | Individual #1 stores their medications on their dining room table. They are not stored in a locked container. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 1. A plan to fix the immediate problem.
a. WHO: QLS Medical Coordinator, management and Steff
b. WHAT: QLS Medical Coordinator will ensure all medications are stored properly and disposed of properly if necessary. QLS management will inspect the medication storage weekly during unannounced inspections. QLS staff will ensure proper storage/disposal daily of medications
c. WHEN and HOW: QLS Medical Coordinator will ensure that all homes are equipped with a locked medication box, and instructions for disposing of refused medications by 2/1/2023. |
02/02/2024
| Implemented |
| 6400.182(c) | Individual #1's ISP is contradictory regarding their supervision levels. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 1. A plan to fix the immediate problem.
a. WHO: QLS Program Specialists
b. WHAT: QLS Program Specialists will ensure immediate updates to individual plans based on the latest assessment and any change of needs that occur, by conducting timely and accurate addendums and revisions as needed.
c. WHEN and HOW: QLS program specialists developed a streamlined communication process between the departments for accurate information regarding revisions and updates to individual plans, this was put into effect on 1/22/2024. |
02/02/2024
| Implemented |